Sexual Assault Help Center Client Information Sheet

Sexual Assault Help Center Client Information Sheet

All information provided is protected under SAHC's Confidentiality Agreement. If you are unfamiliar with SAHC's confidentiality requirements or wish to know why we request this information, please feel free to ask any SAHC staff person for assistance.

Which advocate sent you this form to fill out?
If you selected "Other," please explain.

College Student/Title IX Information
Are you currently a college student?
Are you completing these intake forms due to a recent incident that occurred on a college campus?

College Student/Title IX Information
What college do you attend?
Campus where the abuse take place
What is your relationship to the abuser?
What type of abuse occurred?
What is the general area where abuse took place?
What is the approximate time of day the abuse took place?
What day did the abuse take place?

Month Day Year
Date
Has the abuse been reported to Title IX?
Do you wish to report the abuse to Title IX?

Victimizations
Type of abuse/violence that occurred
How old were you when this abuse occurred?
Relationship to the abuser
Do you need medical attention at this time?
Was the abuse reported?
Who was the abuse reported to?

Child Protective Services (CPS) Adult Protective Services (APS) Law Enforcement Prosecutor
Did the abuse take place in prison/jail?
What is the name of the prison/jail?
Name of abuser
Estimated age of abuser
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code County
Has the abuser served in the military?
Comments or anything else that you would like to list or may know about your abuser?

Do you have another victimization you would like us to know about?

Yes No

Victimization
Type of abuse/violence that occured
How old were you when this abuse occurred?
Relationship to abuser
Do you need medical attention at this time?
Was the abuse reported?
Who was the abuse reported to?

Child Protective Services (CPS) Adult Protective Services (APS) Law Enforcement Prosecutor
Did the abuse take place in prison/jail?
What is the name of the prison/jail?
Name of abuser
Estimated age of abuser
Gender
Address

Street Address

City State / Province

Postal / Zip Code
Has the abuser ever served in the military?
Comments or anything else that you would like to list or may know about your abuser?

Do you have another victimization that you would like us to know about?

Yes No

Victimizations
Type of abuse/violence that occurred
How old were you when this abuse occurred?
Relationship to the abuser
Do you need medical attention at this time?
Was the abuse reported?
Who was the abuse reported to?

Child Protective Services (CPS) Adult Protective Services (CPS) Law Enforcement Prosecutor
Did the abuse take place in prison/jail?
What is the name of the prison/jail?
Name of abuser
Estimated age of abuser
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Has the abuser ever served in military?
Comments or anything else that you would like to list or may know about your abuser?

Notice of your Right to Confidentiality
Safety is a priority of our program. To respect your privacy and help support your safety and right to make your own decisions, we will make every effort to keep what you tell us confidential. Confidential information includes:

- Any written or spoken communication between a person seeking/receiving service and any program staff, volunteer, or board member.

- Any records of written information identifying a person to whom services are provided.

- Any information about services provided to an individual.

We will not disclose anything about you without your permission, unless a legal exception exists. Legally, we are obligated to release confidential information when required by court of law or subpoenaed. We will immediately inform you in the event that this occurs.

We are mandated reporters meaning that we are required by law to contact the Department of Health and Human Services (DHHR) in the event that there is suspicion of child abuse or neglect and/or abuse and neglect of a mentally incapacitated individual. We are also required by law to contact the local law enforcement when there is a "threat of life" to include suicidal behavior and/or threat to harm others that would result in serious physical injury or death.

It is your choice to decide what information you share about yourself and you may change your mind and withdraw the release of information at any time. You do not have to give permission or sign a release of information in order to receive services. It is completely your decision. You may find it helpful for us to share specific and limited information with other agencies and programs. You can choose to give permission so that we can release specific information about you. If you decide that we can share your information, this will be done by signing a Release of Confidential Information form. However, we will still protect your privacy and confidentiality to the best of our abilities. Please note that if you sign a release of information, you do not give up your right to have the released information protected under other laws or rules.
I understand the information provided on this form. *
Please initial

Client's Bill of Rights
You, as the client, have the right to:

1. Receive respectful assistance.

2. Experience a safe setting, free from physical, sexual, or emotional abuse.

3. Refuse assistance or a particular intervention strategy.

4. Ask questions at any time.

5. Know how available the advocate/supportive counselor is to see you or what the waiting period is.

6. Have information regarding the advocate/supportive counselor's areas of specialization and limitations.

7. Have consults with each advocate to choose which one you feel most comfortable with.

8. Talk about any part of your assistance with anyone you choose.

9. Be provided information about limitations of confidentiality and mandatory reporting.

10. Disclose any personal information and refuse to answer any questions asked.

11. Require the advocate/supportive counselor to send a report regarding your assistance with your written authorization only.

12. Have access to summaries of written and taped files about you at your request, when legally possible.

13. Terminate assistance at any time.

Advocacy and supportive counseling is confidential. Information that is shared by you in an advocacy/supportive counseling session will be treated with the highest regard for confidentiality.

SAHC is an equal opportunity agency, this program does not, by act or deed, discriminate against any person desiring assistance based on race, creep, national origin, sex, sexual orientation, age, disability, or socio-economic background.
I understand the information provided on this form. *
Please initial

Complaint Procedure for Recipients of Service
The staff and advocates of the Sexual Assault Help Center strive to provide the most appropriate and sensitive delivery of services to the clients served.

As a recipient of services through SAHC, if you have a complaint regarding a service and/or the service provider you are asked to follow the complaint procedure listed below.

1. When possible, address the complaint on the level it has occurred (with the appropriate staff person and/or advocate).

2. If you are not satisfied with the result of the first procedure or if you feel it is not possible to address complaint on the level where it is occurring, you can contact the Executive Director of SAHC at (304) 234-1783 for an informal hearing on your complaint. The staff/advocate who is involved in the complaint will be informed that a probably may/does exist.

3. If the solution to the complaint is not satisfactory to the recipient of services, a written appeal can be submitted to the SAHC Board of Directors' Personnel Committee. This complaint with then be presented to the Personnel Committee no later than the next scheduled board meeting.

4. The complainant will be information of what action will be taken at that point.

Levels of Services and Supervision

SAHC Board of Directors

|

SAHC Executive Director

|

SAHC Victim Advocates
|

SAHC Volunteer Advocates
I understand the information provided on this form. *
Please initial

Client Information Checklist
As a recipient of services through the Sexual Assault Help Center, I understand I have the following rights and responsibilities. By checking the boxes next to each item, I confirm this information has been received and signed.

SAHC's Notice of Your Right to Confidentiality SAHC's Client's Bill of Rights SAHC's Complaint Procedure for Recipients of Services SAHC's Consent for Services Involving a Minor (if applicable) SAHC's Consent for Services Involving an Adult with Guardianship (if applicable)
I understand that all services provided by SAHC are at no cost to me. *
Please initial
I understand that I may discontinue services with SAHC at any time unless services are ordered by a legal entity. *
Please initial
I understand the information provided on this form. *
Please initial

Consent for Services
Who are you filling this form out for? *

Myself A minor An adult with legal guardianship

Consent for Services Involving a Minor
I, parent name , as the parent/guardian of, child/minor name, Birthdate: birthdate give the Upper Ohio Valley Sexual Assault Help Center (SAHC) permission to provide services to said child/minor.
It is my understanding that these services may consist of child sexual abuse prevention education, advocacy, and/or supportive counseling services requested as a result of alleged or proven child sexual abuse.

The services of SAHC are provided at NO COST to the participants, are entered into VOLUNTARILY (unless otherwise court ordered), can be TERMINATED at any time by the parent/legal guardian and/or SAHC.
I understand the information provided on this form.
Please initial

Consent for Services Involving an Adult with Guardianship
I, blanks, as the legal guardian of: Birthdate: , give the Upper Ohio Valley Sexual Assault Help Center (SAHC) permission to provide services to said adult with guardianship.
It is my understanding that these services may consist of sexual abuse prevention education, advocacy, and/or supportive counseling services requested as a result of alleged or proven sexual abuse.

The services of SAHC are provided at NO COST to the participants, are entered into VOLUNTARILY (unless otherwise court ordered), and can be TERMINATED at any time by the legal guardian and/or SAHC.
I understand the information provided on this form.
Please initial

Signature and Submit

By signing this form, I understand all of the information provided and agree to the information being provided to my advocate.
Signature *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Sexual Assault Help Center Client Information Sheet

College Student/Title IX Information

College Student/Title IX Information

Victimizations

Victimization

Victimizations

Notice of your Right to Confidentiality

Client's Bill of Rights

Complaint Procedure for Recipients of Service

Client Information Checklist

Consent for Services

Consent for Services Involving a Minor

Consent for Services Involving an Adult with Guardianship

Signature and Submit